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HomeMy WebLinkAboutSludge Tank, Grease Trap, - Septic Pumping Slip - 351 WILLOW STREET 2/3/2022 Commonwealth of Massachusetts RECEIVED City/Town of No. Andover FEB 0 3 2022 ~' System Pumping Record Form 4 TOWN OF N'':� TH ANDOVER HEALTH G`PARTMENT rG^M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not No. Andover MA use the return City/Town State Zip Code key. �1 2. System Owner: V� I Name �n Address(if different from location) Citylrown State Zip Code Telephone Number ---B. Pumping Record - -- - - ------ - 7, 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): S��� C 4. Effluent Tee Filter present? ❑ Yes E No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed cgndition of component pumped: 6. System Pumped B, Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradford, MA J � �' �� Signatur of Hauler Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11112 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts W City/Town of No. Andover FEB 0 3 2022 System Pumping Record Form 4 TC E OF NORTH ER LLTH DEPARTMENT �M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, /�/v� use only the tab key to move your Address cursor-do not No. Andover 01845 use the return MA key. City/Town State Zip Code m 2. System Owner: Name - iwm Address(if different from location) Citylrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping - ' Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap Oher(describe): �- 4. Effluent Tee Filter present? ❑ Yes V>No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 8 6. S ste PumRed By: Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20 So. Mill St., Bradfo d, MA atu of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED r City/Town of No Andover FEB o 3 2022 System Pumping Record 4"!�F NO T H HNDOVER mar•` Form 4 E--;,.TH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, z use only the tab 95Y �&4/el/ 5 7—/f key to move your Address cursor-do not use the return City/Town State Zip Code key. 2. System Owner: raS Name remm Address(if different from location) No Andover MA City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Gallo 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank n rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component ped: 6. SystertsPu p By: -3�- � Name Vehicle License Number Stewart's Septic 58 So Kimball St. , Bradford,MA Company 7. .Location where contents were disposed- Mill So Mill St. dford,MA,.= Signature of ufer= Date v' Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED W City/Town of No. Andover FEB 0 3 2022 System Pumping Record Form 4 TOWN 0�=NORTH ANDOVEP HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 35 J V key to move your Address cursor-do not No. Andover _ MA use the return City/Town State Zip Code key. 2. System Owner: ' r 30 Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gal ns 3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank rease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes L—Ko- If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component ped: 6. Sys em P mped By �Cz9 C, J - Name Vehicle License Number Stewart's Septic 58 So. Kimball St., Bradford,MA Company 7. Location where contents were disposed: 20.S . Mill Bradford, 4 � f Hau' Date Same day Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1